Plan Administrator: Seven Corners | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
SCHEDULE OF BENEFITS
INJURY AND SICKNESS MEDICAL BENEFITS (PART A)
Maximum Benefit Limit Per Sickness or Injury:
Ages 14 days through 69: Option $50,000 (Plan A), $75,000(Plan B),$100,000 (Plan C),or$130,000(PlanD)
Deductible Per Person Per Sickness or Injury:
Ages 14 days through 69: Option $0, $50, or $100
No Coinsurance applies.
|
Age 14 Days through 69 |
Plan A |
Plan B |
Plan C |
Plan D |
|
Medical Maximum |
$50,000 Max per Injury/Sickness |
$75,000 Max per Injury/Sickness |
$100,000 Max per Injury/Sickness |
$130,000 Max per Injury/Sickness |
|
Deductible Per Person Per Sickness or Injury |
$0, $50, or $100 |
$0, $50, or $100 |
$0, $50, or $100 |
$0, $50, or $100 |
|
INPATIENT |
|
|
|
|
|
Hospital Room & Board Including Laboratory Tests, X-Rays, Prescription Medical, Extended Care Facility and other miscellaneous |
Up to$1,500/day, 30 day max |
Up to $2,000/day, 30 day max |
Up to $2,500/day, 30 day max |
Upto$3,000/day, 30 day max |
|
Hospital Intensive Care Unit |
Additional$500/day, 8 day max |
Additional$500/day, 8 day max |
Additional$500/day, 8 day max |
Additional$800/day, 8day max |
|
Surgical Treatment |
Up to $2,100 |
Up to $4,800 |
Up to $5,800 |
Up to $7,200 |
|
Anesthetist |
Up to $500 |
Up to $750 |
Up to $1,000 |
Up to $1,650 |
|
Assistant Surgeon |
Up to $500 |
Up to $750 |
Up to $1,000 |
Up to $1,650 |
|
Physician’s Non-Surgical Visits |
Up to $60/visit, 1/day,10 visits max |
Up to $75/visit, 1/day, 10 visits max |
Up to $90/visit, 1/day, 10 visits max |
Up to $115/visit, 1/day, 10visits max |
|
Private Duty Nurse |
Up to $650 |
Up to $650 |
Up to $650 |
Up to $650 |
|
A Consulting Physician, when requested by attending Physician |
Up to $250 |
Up to $325 |
Up to $500 |
Up to $575 |
|
Pre-Admission Tests w/in7 days before Hospital admission |
Up to $650 |
Up to $975 |
Up to $1,300 |
Up to $1,300 |
|
OUTPATIENT |
|
|
|
|
|
Surgical Treatment |
Up to $2,100 |
Up to $4,800 |
Up to $5,800 |
Up to $7,200 |
|
Anesthetist |
Up to $500 |
Up to $750 |
Up to $1,000 |
Up to $1,650 |
|
Assistant Surgeon |
Up to $500 |
Up to $750 |
Up to $1,000 |
Up to $1,650 |
|
Physician’s Non-Surgical/Urgent Care Visits |
Up to $60/visit, 1/day,10visit max |
Up to $75/visit, 1/day,10 visits max |
Up to $90/visit, 1/day,10 visit max |
Up to $115/visit, 1/day, 10 visits max |
|
Diagnostic X-rays & Lab Services |
Up to $250 - Additional $325- One CATscan,PET scan or MRI |
Up to $375 - Additional $325 - One CAT scan, PET scan or MRI |
Up to $500 - Additional $975 – One CAT scan PET scan or MRI |
Up to $575 -Additional $975 - One CAT scan, PET scan or MRI |
|
Hospital Emergency Room (all expenses incurred therein) |
Up to $200 |
Up to $500 |
Up to $575 |
Up to $750 |
|
Prescription Drugs |
Up to $250 Per Period of Coverage |
Up to $250 Per Period of Coverage |
Up to $250 Per Period of Coverage |
Up to $250 Per Period of Coverage |
|
Outpatient Surgical Facility - Day surgery miscellaneous, related to outpatient scheduled surgery performed at a Hospital or licensed outpatient surgery center;including the cost of the operating room, anesthesia, drugs and medicines and medical supplies. |
Up to $600 |
Up to $900 |
Up to $1,200 |
Up to $1,400 |
|
OTHER TREATMENT AND SERVICES |
|
|
|
|
|
Ambulance Services |
Up to $500 |
Up to $500 |
Up to $500 |
Up to $500 |
|
Initial Orthopedic Prosthesis/brace |
Up to $663 |
Up to $994 |
Up to $1,325 |
Up to $1,600 |
|
Durable Medical Equipment |
Up to $1,100 |
Up to $1,200 |
Up to $1,300 |
Up to $1,700 |
|
Chemotherapy and/or radiation therapy |
Up to $663 |
Up to $994 |
Up to $1,325 |
Up to $1,600 |
|
Dental Treatment for Injury to Sound, Natural Teeth |
Up to $650 |
Up to $650 |
Up to $650 |
Up to $650 |
|
Mental & Nervous Disorder&Substance Abuse |
Same as any Sickness |
Same as any Sickness |
Same as any Sickness |
Same as any Sickness |
|
Emergency Evacuation Physiotherapy |
$50,000 Up to $45/visit, 1/day, 12 visits max |
$50,000 Up to $45/visit, 1/day, 12 visits max |
$50,000 Up to $45/visit, 1/day, 12 visits max |
$50,000 Up to $45/visit, 1/day, 12 visits max |
|
Extended Care Facility |
Covered under the Hospital Room & Board benefit |
Covered under the Hospital Room & Board benefit |
Covered under the Hospital Room & Board benefit |
Covered under the Hospital Room & Board benefit |
|
Return of Remains/ Local Cremation/Burial |
$25,000 $5,000 |
$25,000 $5,000 |
$25,000 $5,000 |
$25,000 $5,000 |
|
Home Country Coverage |
$50,000 |
$50,000 |
$50,000 |
$50,000 |
|
Common Carrier AD&D |
$25,000 Principal Sum |
$25,000 Principal Sum |
$25,000 Principal Sum |
$25,000 Principal Sum |
|
Acute Onset of Pre- existing Condition(s) |
$50,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation |
$75,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. |
$100,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. |
$130,000 per Period of Coverage for Medical Expense Benefits (subject to the sublimits for each benefit shown above) & $25,000 per Period of Coverage for Emergency Medical Evacuation. |
EMERGENCY EVACUATION AND RETURN OF REMAINS (PART B)
| BENEFIT | MAXIMUM AMOUNT |
|---|---|
| Emergency Evacuation | $50,000 maximum benefit per Injury or Sickness |
| Return of Remains | $25,000 maximum benefit |
COMMON CARRIER ACCIDENTAL DEATH & DISMEMBERMENT (PART C)
| BENEFIT | PRINCIPAL SUM |
|---|---|
| Accidental Death & Dismemberment | $25,000 |
BENEFIT PERIOD & HOME COUNTRY COVERAGE
“BENEFIT PERIOD” shall mean the duration of time following an Eligible Accident, Injury or Illness in which to receive Medically Necessary Covered Expenses. If Your plan terminates during Your Benefit Period, You will still be eligible to receive Treatment so long as the treatment is within Your Benefit Period and outside Your Home Country (except as provided under the Home Country Coverage). Treatment due to an Injury must be performed by a Physician and meet the following conditions: a) begin within thirty (30) days after date of Injury; and b) be received within three hundred and sixty-four (364) after date of Injury; or Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within three hundred and sixty-four (364) after the date of first treatment for such Sickness.
HOME COUNTRY COVERAGE
Incidental Trips to Your Home Country: This benefit covers the Insured Person for incidental trips to his or her Home country (30 days per three hundred and sixty-four (364) days of purchased coverage or pro rata thereof – example: approximately 2½ days per 30 days of purchased coverage). Maximum benefit is reduced to $50,000 for any illness or injury occurring while on an incidental trip to the Home Country.
PRE-EXISTING MEDICAL CONDITIONS
"PRE-EXISTING CONDITION” shall mean any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting there from that with reasonable medical certainty existed at the time of application or within the one hundred and eighty (180) days immediately prior to the Insured Person’s Effective Date under the Certificate, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the one hundred and eighty (180) days immediately preceding the effective date of coverage under this Certificate.
MEDICAL EXPENSE BENEFITS – INJURY AND SICKNESS
When a covered Injury or Sickness requires treatment by a Physician, the Certificate will provide benefits for the maximum benefit amount payable per service as specified in the Schedule of Benefits for Medically Necessary Covered Medical Expenses which exceed the deductible per person for each Injury or Sickness. The total payable for all Covered Medical Expenses will be no more than the Maximum Benefit Limit per Sickness or Injury.
Benefits are subject to the Excess Provision.
Covered Medical Expenses will be paid under the Schedule of Benefits for loss:
1. Due to Injury to an Insured Person provided that treatment by a Physician: a) begins within thirty (30) days after date of Injury; and b) is received within three hundred and sixty-four (364) days after date of Injury; or
2. Due to Sickness of an Insured Person provided Covered Medical Expenses are incurred within three hundred and sixty-four (364) days after the date of first treatment for such Sickness.
If a benefit is designated in the Schedule of Benefits, Covered Medical Expenses include:
1. Room and Board Expense: 1) daily semi-private room rate when Hospital Confined; and 2) general nursing care provided and charged for by the Hospital.
2. Intensive Care.
3. Hospital Miscellaneous Expenses: 1) while Hospital Confined; or 2) for pre-admission expenses for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; x-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies.
4. Physiotherapy (inpatient).
5. Surgery: Physician’s fees for inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this inpatient surgery benefit; or under the outpatient surgery benefit, but not for both.
6. Anesthetist Services: in connection with inpatient surgery.
7. Private Duty Nurse’s Services: 1) private duty nursing care only; 2) while Hospital Confined; 3) ordered by a licensed Physician; and 4) a Medical Necessity. General nursing care provided by the Hospital is not covered under this benefit.
8. Physician’s Visits: when Hospital Confined. Benefits are limited to one Physician’s visit per day. Benefits do not apply when related to surgery. Covered medical expenses will be paid under the inpatient benefit or under the outpatient benefit for Physician’s Visits but not both.
9. Pre-admission Testing: limited to routine tests such as: complete blood count; urinalysis; and chest x-ray. If otherwise payable under the Certificate, major diagnostic procedures such as: cat-scans; NMR’s; and blood chemistries will be paid under the “Hospital Miscellaneous” benefit.
10. Mental and Nervous Disorder (inpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one Physician’s visit per day.
11. Surgery (outpatient): Physician’s fees for outpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. Covered medical expenses will be paid under this outpatient surgery benefit; or under the inpatient surgery benefit, but not both.
12. Day Surgery Miscellaneous (Outpatient): in connection with outpatient day surgery; excluding non-scheduled surgery, and surgery performed in a Hospital emergency room, trauma center, Physician’s office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and x-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies.
13. Anesthetist (Outpatient): in connection with outpatient surgery.
14. Physician’s Visits (Outpatient): Includes injections administered during visit. Benefits do not apply when related to surgery or Physiotherapy. Covered medical expenses will be paid under the outpatient benefit or under the inpatient benefit for Physician’s visits but not both.
15. Medical Emergency Expenses (Outpatient): only in connection with a Medical Emergency as defined. Benefits will be paid for the use of the emergency room and supplies.
16. Radiation Therapy (Outpatient)
17. Chemotherapy (Outpatient)
18. Prescription Drugs (Outpatient)
19. Mental and Nervous Disorder (Outpatient): the benefits and the maximum amounts are specified in the Schedule of Benefits. Benefits are limited to one Physician’s visit per day.
20. Ambulance Service.
21. Braces and Appliances: 1) when prescribed by a Physician; and 2) a written prescription accompanies the claim when submitted. Replacement braces and appliances are not covered. Braces and appliances include Durable Medical Equipment (consisting of a standard basic hospital bed and/or a standard basic wheelchair). No benefits will be paid for rental charges in excess of purchase price.
22. Consultant Physician Fees: when requested and approved by the attending Physician.
23. Dental Treatment: 1) performed by a Physician; and 2) made necessary by Injury to Sound, Natural Teeth. Routine dental care and treatment to the gums are not covered.
24. Alcoholism/Drug Abuse Treatment: the benefits and the maximum amounts are specified in the Schedule of Benefits.
25. Care in an Extended Care Facility following direct transfer from an acute care Hospital, provided such care is recommended by the Physician for convalescence related to the Illness or Injury for which the Member was hospitalized as Inpatient. Extended Care Facility benefits accrue toward the limits for Hospital Room and Board.
EMERGENCY EVACUATION
The Company will pay benefits for covered expenses incurred up to a maximum of $50,000, if an Injury or Sickness commencing during the Period of Coverage results in the necessary Emergency Evacuation of the Insured Person. An Emergency Evacuation must be ordered by a legally licensed Physician who certifies that the severity of the Insured Person's Injury or Sickness warrants the Emergency Evacuation of the Insured Person.
Benefits are subject to the Excess Provision.
Emergency Evacuation means:
1) the Insured Person's medical condition warrants immediate transportation from the place where the Insured Person is injured or sick to the nearest Hospital where appropriate medical treatment can be obtained; or
2) after being treated at a local Hospital, the Insured Person's medical condition warrants transportation to the place where he or she resides to obtain further medical treatment or to recover; or
3) both a) and b) above.
Covered expenses are expenses, up to the maximum, for transportation, medical services and medical supplies necessarily incurred in connection with emergency evacuation of the Insured Person.
All transportation arrangements made for evacuating the Insured Person must be by the most direct and economical route. Seven Corners Assist must make all arrangements and must authorize all expenses in advance for any Emergency Evacuation benefits to be payable
Covered expenses must be: (a) recommended by the attending Physician; (b) required by the standard regulations of the conveyance transporting the Insured Person; and (c) authorized in advance by Seven Corners Assist.
Transportation means any land, water or air conveyance required to transport the Insured Person during an emergency evacuation. Transportation includes, but is not limited to, air ambulance, land ambulance, and private motor vehicles.
RETURN OF REMAINS / LOCAL CREMATION OR BURIAL
The Company will pay the reasonable Covered Expenses incurred up to $25,000 to return the Insured Person's remains to his/her Home Country, if he or she dies. Covered Expenses include, but are not limited to, expenses for embalming, [a minimally necessary container appropriate for transportation, shipping costs, and the necessary government authorizations. All transportation arrangements must be performed by the Administrator.
The Company will pay the reasonable Eligible Expenses incurred up to the maximum stated in the SCHEDULE OF BENEFITS for preparation, local burial or cremation of the Insured Person’s mortal remains at the place of death in accordance with the commonly accepted cultural and religious beliefs practiced by the Insured Person. Coverage is not provided for burial and cremation costs incurred for religious practitioner, flowers, music, food or beverages.
If the Local Cremation or Burial is chosen, the Return of Mortal Remains benefit will not apply.
INTERNATIONAL TRAVEL COVERAGE
An insured person may travel to additional countries, other than the United States, up to a maximum of 30 days. You must purchase a minimum of thirty (30) days of coverage. International travel coverage does not include travel back to the insured person’s Home Country, and it does not extend after your current expiration date. International travel must be utilized during your current Period of Coverage.
COMMON CARRIER ACCIDENTAL DEATH AND DISMEMBERMENT INDEMNITY
Accidental Death & Dismemberment Coverage shall apply only to covered accidents sustained by an Insured Person:
1) While riding as a passenger (but not as a pilot, operator or member of the crew) in or on (including getting in or out of, or on or off of):
A) any land, water or air conveyance operated under a license for the transportation of passengers for hire; or
B) any Military Air Transport Aircraft; or
2) By being struck down by any aircraft.
The Company shall pay an indemnity determined from the Table of Losses below if an Insured Person sustains a loss stated therein resultingfrom Injury, provided that:
(a) such loss occurs within three hundred and sixty five (365) days after the date of accident causing such loss; or
(b) the indemnity payable for any such loss shall be the amount stated opposite such loss in said Table and the Principal Sum stated therein shall be the amount stated in the Schedule of Benefits, as applicable to such person and this Coverage; and
(c) if more than one loss stated in said Table is sustained as the result of one accident, only one of the amounts so stated in said Table, the largest, shall be payable.
| For Loss of: | Indemnity |
|---|---|
| Life | Principal Sum |
| Both Hands or Both Feet or Sight of Both Eyes | Principal Sum |
| One Hand and One Foot | Principal Sum |
| Either Hand or Foot and Sight of One Eye | Principal Sum |
| Either Hand or Foot | One-Half the Principal Sum |
| Sight of One Eye | One-Half the Principal Sum |
The term “loss” as used herein shall mean with regard to hands and feet, actual severance through or above wrist or ankle joints, and with regard to eyes, entire irrecoverable loss of sight.